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PROVIDER SERVICES MANUAL
STANDARDS FOR HEALTH SERVICES DELIVERY TO WISCONSIN
DEPARTMENT OF CORRECTIONS INMATES/YOUTH
DIVISION OF ADULT INSTITUTIONS
DIVISION OF JUVENILE CORRECTIONS
BUREAU OF HEALTH SERVICES
2006
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TABLE OF CONTENTS
TITLE
PAGE NUMBER
MISSION, VISION AND GOALS
3
PURPOSE
4
PATIENT TYPES
4
INFORMED CONSENT FOR HEALTH SERVICES
4
EXPECTATIONS OF PROVIDERS
- Consent for care
- Discharge planning
- Emergency care
- Follow up care – Off site
- Follow up care – Outpatient referral
- Hospitalizations
- Infirmary admissions requirements
- Durable Medical Equipment
- Confidentiality
- Medications
- Off site options
- Off site service request
- Outpatient referrals
- Prostheses
- Security Issues
5
5
5
5
6
6
7
7
7
8
8
8
9
9
9-10
BHS ADMINISTRATION PHONE NUMBERS
BHS STAFF DIRECTORY BY INSTITUTIONS
DIRECTORY FOR CORRECTIONAL CENTERS
HEALTH SERVICE PROGRAMS FOR ADULTS/YOUTHS
MEDICAL/SURGICAL CLASSIFICATION
HEALTH SERVICES WITHIN THE INSTITUTIIONS
NURSING HOURS
HANDICAP ACCESSIBILITY
CASE MANAGEMENT
OFFSITE REQUEST
CLASSIFICATION OF MEDICAL CONDITION
FORMULARY
INMATE HEALTH PLAN
11
12-14
15-16
17-19
20-21
22-27
28
29
30
31
32
33
34
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BUREAU OF HEALTH SERVICES
MISSION
The purpose of DOC health care delivery system is to provide needed health care
for individuals in a correctional facility which is cost effective and meets
community standards appropriate to the correctional environment.
VISION
Provide high quality correctional health services through cost-effective medical, dental, and
mental health care (Wis Admin Code, Chapter 302).
GOALS
Provide inmate health care at a cost below HMO inflationary increases based on a per inmate
per year expenditure rate measure.
Strive to decrease the daily cost of hospitalizations for inmates requiring specialized care found
in regional medical facilities.
Develop a regional strategy to consolidate medical hospital / health system services to leverage
BHS position with providers and improve the continuity of care.
Develop meaningful long term business relationships that benefit BHS and the provider
community.
Automate pharmaceutical services to accommodate existing capacity and expand service to
surrounding jails.
Develop a centralized medical supply warehouse to achieve standardization in the types and
cost of supplies used by the health service units.
Enhance delivery of mental health services by improving multi-disciplinary collaboration.
Improve quality and timeliness of health services as evidenced by lower inmate health care
complaints and decreased inmate lawsuits.
Automate and electronically link medical related functions for the purpose of providing quality,
timely, cost efficient inmate services i.e. pharmacy, radiology and medical records.
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Purpose
This manual is provided to facilitate the care and treatment of inmates/youth in the Wisconsin Department of
Corrections(WDOC) by local outpatient and inpatient health care providers
Patient Types
Adult:
Male or female 18 years of age or older.
Offender:
Male or female of any age convicted in a criminal court and generally residing in a
correctional facility operated by the Department of Health and Family Services(e.g.
Wisconsin Resource Center). A small number of inmates under the age of 18 years
reside in a correctional facility operated by the Division of Juvenile Corrections or the
Department of Health and Family Services(e.g. Mendota Juvenile Treatment Center).
Minor/juvenile:
Male or female under the age of 18 years residing in a correctional facility operated by
the Division of Adult Institutions, Division of Juvenile Corrections or Department of
Health and Family services. Regardless of location, a minor lacks legal authority to
consent for treatment except as explained in the section regarding informed consent for
treatment.
Youth:
Males or females up to age 25 adjudicated delinquent and residing in a correctional
facility operated by the Division of Juvenile Corrections.
Informed Consent for Health Care Services
Individuals age 18 years or older must consent to the health care services except when a court order directs
that the WDOC provide specific health care services to the individual.
Individuals under the age of 18 years old lack legal authority to consent to the receipt of health care services
except as described below. A parent/guardian or other individual legally authorized to consent for the minor
must consent for healthcare services for a minor except for routine health care services provided by a
correctional facility or off-site health care provider to whom WDOC has referred the minor.
A minor has legal authority to request and/or consent to certain inpatient and outpatient treatment for alcohol
or drug abuse, developmental disabilities or mental health problems under chapter 51, State Alcohol, Drug
Abuse, Developmental Disabilities and Mental Health Act, Wisconsin Statutes.
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Expectations of Providers in Collaboration with WDOC
Consent for Care and Treatment

Adult inmates must consent to care and treatment.

WDOC may on occasion obtain court orders for assessment, care and treatment should the
inmate’s/youth’s life be considered to be in danger.

Juveniles in adult facilities must have parental consent before any invasive procedures—should
parents/ guardians be unavailable, court orders will be needed before proceeding.

Youth in juvenile correctional facilities must have parental consent before any invasive
procedures—should parents/guardians be unavailable, court orders or the facility superintendent’s
consent will be needed before proceeding.
Discharge Planning

Advance discharge planning between the local health care provider and the receiving health
care facility is essential to enable correctional health care to provide appropriate post hospitalization
patient care and make the necessary arrangements for medication, supplies, etc. Facilities do not have
24 (twenty-four) hour on-site health care or pharmacy coverage on PMs, nights, or weekend shifts. A
twenty-four (24) hour notice of discharge is the minimum requirement needed to provide continuity of
care by Corrections.

The Bureau’s Discharge Planners will monitor hospitalizations of patients, provide updates on their
conditions, and plan for their discharge. A local physician to correctional physician contact is required
before the discharge occurs. Transportation will be arranged by correctional staff. Advance notice is
needed.

A discharge summary, admission history and physical, lab and x-ray reports, and any other pertinent
medical records should accompany the offender / youth upon their return to either the Infirmary or a
regular DOC facility. It is best to avoid discharging offenders / youth on the PM or night shifts or
weekends due to the unavailability of nursing staff, new medication orders and the difficulty of
arranging transportation during this period.
Emergency Care

Emergency care is managed through the local emergency room.

Once the offender / youth is stabilized, placement is dependent on the medical need.

If admission to a hospital is necessary adults are usually transferred to UWHCA, which is facilitated,
by the local hospital and the UWHCA physician or to a local contractual hospital. Adolescents in the
juvenile system may remain in the local hospital after consultation with the correctional facility’s
Health Services Manager.
Follow Up Care and Treatment—Off Site

Must be scheduled through the Health Services Unit, not the correctional officers or the inmate.
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
There are limitations as to the number of appointments that can be made daily from each institution
and as a result appointments must be prioritized as to the need of the involved offenders.

Please consider whether the primary physician at the institution may do activities such as suture
removal(after consultation with the specialty physician).

For security and safety reasons, offenders may not know the date and time of their next
appointment. Appointments known to the offender will be cancelled and rescheduled.
Follow Up Care by the Institutions after an Outpatient Clinical Referral

After consultation, the primary care physician at the respective correctional facility renders follow-up
care as recommended by the specialist unless there are special indications for a return visit.

The Health Services Unit physician and/or other health care staff may consult by telephone with the
specialty clinic’s physicians and/or staff to promote continuity of health care.

Schedule return visits to the clinic only when necessary as the distance from the clinic and security
requirements increases the cost of each visit.

Telemedicine capabilities are available at some facilities and the DOC will continue to develop
this technology to assure public safety and cost savings.
Hospitalizations

Admissions: Except in emergency situations, contact the primary care physician or designee of the
respective facility before admitting an offender/ youth. Hospitalization may be in the security unit of
the UWHCA for adult males, at Waupun Memorial Hospital, or in a local contractual hospital.
Females and juveniles are hospitalized in other UWHCA units or in local hospitals.

Cancellations: If for any reason a scheduled operation or other procedure is canceled after the
offender/youth has been admitted, please notify the respective Health Service Unit. The
offender/youth may need to be discharged and returned to the institution if this occurs. When the
surgery or procedure is rescheduled, the offender/youth will be readmitted.

Prior authorization during hospitalization: No surgery or procedures other than those for which
the offender/youth was admitted should be performed without first contacting the respective
primary care physician, the Health Services Unit Manager, or the health services staff at the
Correctional Centers.

Case management for the Bureau of Health Services will be done by Discharge Planners located in
Central Office. They will monitor the care and treatment of hospitalized offenders and plan their
discharge for continuity of care with local care providers and the correctional health care staff.
The discharge Planners will contact local care providers for condition updates on patients. They
need to know potential discharge dates to facilitate transfer back to the sending facility or to
another facility which will meet the patient’s discharge needs. Conferences between physicians
may need to be arranges by the Discharge Planners.
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
It is expected that prescriptions ordered whenever possible follow the Central Pharmacy Services,
WDOC Formulary(a copy enclosed with this document).

Diagnostic studies which may have been done at the correctional facility as well as data from the
offender/youth medical record will be made available to the inpatient care providers upon request.

Transfer of offenders/youth to other hospitals must be prior coordinated with the Bureau
Discharge Planners and providers in the facility health services units.
Infirmary Admission Requirements

The Infirmary provides care to offenders who are unable to care for their own needs and require
twenty-four (24) hour nursing care. The Infirmary is not an acute care facility. Services provided by
the Infirmary are not offered by health service units in the other DOC facilities and are not available to
adolescents in the juvenile system.
Important steps employed during an offender's admission to the Infirmary are as follows:

Discharge from the sending facility to the Infirmary requires at least 24 hours advance notice.
Additional time is applicable if special equipment or staff training is necessary.

Physician to physician referral is required. Infirmary physicians are available Monday – Friday 08001630. DOC on-call physicians are available after these hours.

If a patient arrives at the Infirmary after 1400 or on a weekend, the staff from the sending facility must
check with the DCI Infirmary staff to assure discharge medications or supplies are available. If the
medications are not available a supply must be sent with the offender to cover the time until the
prescription can be obtained from the DOC Central Pharmacy.

Current laboratory and x-ray reports and a discharge summary should be faxed to the Infirmary prior
to the offender’s arrival. If unable to be faxed prior to their arrival the discharge information from the
facility should arrive with the patient.

Durable Medical Equipment
If special equipment, such as wheelchairs, TENS units, commodes, etc., are needed for an
offender/youth you are caring for, please contact the Health Services Unit Manager to coordinate
obtaining the needed items with the Bureau of Health Services Policies and State of Wisconsin
Procurement Policies.
Medical Information Confidentiality

Officers and Youth Counselors in attendance of offenders/youth are expected to maintain the
confidentiality of any medical information discussed in their presence.

Medical information regarding offenders/youth is expected to be shared with their primary care
provider –Health Services Unit of the facility they reside in and with the Bureau of Health Services
Central Office health care providers upon request.
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
The Department of Corrections will be a HIPAA covered entity effective April 1,2005.
Medications

WDOC has a closed formulary for pharmaceuticals for offenders/youth. A copy of that formulary is
enclosed in this document. Part of discharge planning is to determine the availability of the prescribed
medication before the inmate/youth is discharged. Non-formulary items are approved through a prior
authorization process.

Prescriptions for medications not in the formulary will not be continued in the facility without a review
process. This formulary is available in the back of this manual.

Send medications with the offender that are necessary to continue or contact the Health Services Unit
to determine the availability of the medications because facilities do not have access to a 24-hour
pharmacy.

Utilize generic pharmaceuticals whenever possible.
Off Site Care Options

Offenders in need of hospitalization or specialized medical services are transferred to the UWHCA in
Madison to the Waupun Memorial Hospital and Clinics, or to local hospitals under contract with the
WDOC.

Offenders who experience emergency needs are transported to local hospital emergency rooms.
When stable, the offender may be transferred to the Infirmary, to the UWHC, to Waupun Memorial
Hospital, to a local contractual care provider or returned to their correctional facility.

Pregnant female offenders are transferred to St. Agnes Hospital in Fond du Lac for delivery.
"Off-Site Service Request and Report"

The officers accompanying the offender / youth will bring the Bureau’s “Off Site Service Request and
Report” form for each outpatient visit in a sealed envelope.

This is to be filled out in full during the visit and returned with the officer to the home facility in a
sealed envelope addressed by and to the nursing staff.

Recommendations for treatment made at this consultation visit are to be included on this form. The
primary care physician will receive these recommendations.

The pink copy of this form should remain in the clinic chart for future reference.
Outpatient Clinical Referrals

Non-emergency outpatient care, treatment, and diagnostics must be prior authorized by WDOC
before being done. The institution primary care physician is responsible for submitting a request, the
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request is reviewed and authorized or denied by the Bureau Central Office staff before an appointment
is made.

Admissions: Except in emergency situations, contact the primary care physician or designee of the
respective facility before admitting an offender/ youth.

Diagnostic studies which may have been done at the correctional facility may be made available
to the outpatient specialist upon request for review.

It is expected that prescriptions ordered whenever possible follow the Central Pharmacy Services,
WDOC Formulary(a copy enclosed with this document).

All Health Service Units may refer offenders/youth to specialists.
Prostheses
All prosthetic devices, including hearing aides and artificial limbs, require prior written
authorization by the Bureau of Health Services. Contact the Health Services Unit Manager of the
offender’s / youth’s facility for more information.
Security Issues
Appointment Dates and Times
Offenders/youth and their friends, relatives or associates must not be informed of dates and times of
outpatient or inpatient appointments. If they are given this information the appointment will be
cancelled and need to be rescheduled. This is to prevent contacts with friends, relatives, and associates
while the offender/youth is not in the more controlled environment of a correctional facility.
Confidential Medical Information
Correctional Officers and Youth Counselors may be privy to confidential health information
regarding offenders/youth they are escorting. They are expected to keep information overheard
confidential.
Health Care Provider interactions with Inmate/Youth Patients
Health care providers should not share personal information with offender/youth patients such as their
home address, phone number, family members names and activities, information regarding their daily
activities such as where they go to church, where their children go to school etc.
Restraints
Offenders/Youth may be restrained during outpatient and inpatient care. Restraints may consist
of handcuffs and/or leg iron restraints. Care providers may request removal of restraints to facilitate
care.
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Security Escorts
Offenders/Youth will be escorted by Correctional Officers or Youth Counselors during their
outpatient appointments. They may have Correctional Officers or Youth Counselors in attendance
24/7 during any inpatient hospitalization.
Security/Safety Concerns
Providers are to report any unusual occurrences or concerns to correctional staff as soon as
possible.
Visits and Phone Calls
Offenders/Youth will be restricted from making telephone calls and having visits while inpatients.
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BUREAU OF HEALTH SERVICES
Questions related to individual correctional facilities’ capabilities are addressed in this manual, or may be
discussed by calling the Facility Health Service Unit or the Bureau of Health Services (see Directory).
Questions regarding the Correctional Centers, should be directed to Susan Koon at 920-929-3884 or 608-2405127.
ADMINISTRATION
Bureau of Health Services
3099 E. Washington Avenue, P.O. Box 7925
Madison, WI 53707-7925
General Information 608 240 5120
FAX 608 240 3311
NAME
Director
Medical Director
Mental Health Director
Dental Director
Psychology Director
Pharmacy Supervisor
Medical Records Supervisor
James Greer, RN, MS
David Burnett, MD, MMM
Kevin Kallas, MD
Barbara Ripani, DDS, MPH
Donald Hands, Ph.D
Larry Edwards, R. Ph.
Gloria Marquardt
Nursing Coordinator
Nursing Coordinator
Kathleen Berkley, RN, MS
Susan Koon, RN
Nursing Coordinator
James LaBelle, RN MS
Nursing Coordinator
Cynthia Thorpe, RN
Nursing Coordinator
Nursing Coordinator
Discharge Planner
Discharge Planner
Nursing Specialist-North
Patricia Voermans, RN MS APNP
Sharon Zunker, RN
Linda Kleinsteiber, RN, MS
Lynn Yarbrough, RN, MS
David Rosenbaum, RN
Nursing Specialist-South
Joyce Carol-Deer, RN
BHS Contract Specialist
WDOC Contract Specialist
Dave Schuller
Scott Noreuil
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PHONE NUMBER
608 240 5122
608 240 5124
608 240 5114
608 240 5132
608 240 5112
920 324 6251
608 240 5152
920 324 6370
608 240 5126
608 240 5127
920 929 3884
608 240 5130
262 884 2410
608 240 5131
920 237 2031
608 240 5128
608 240 5121
608 240 5125
608 240 5134
920 236 2743
cell 414 313 2519
414 267 6101
cell 414 313 2520
608-240-5134
608-240-5588
BHS STAFF DIRECTORY BY INSTITUTION
DEPARTMENT OF CORRECTIONS HEALTH SERVICES (HSU)
FACILITY
Chippewa Valley Correctional Treatment
Facility
Phone 715 720 2850
HSU Fax 715 720 3635
Columbia Correctional Institution
Phone 608 742 9100
HSU Fax 608 742 9119
Dodge Correctional Institution
Primary Care
Phone 920 324 5577
HSU Fax 920 324 6288
Dodge Correctional Institution
Infirmary
Hemodialysis
Phone 920 324 5577
HSU Fax 920 324 6301
Ethan Allen School
Phone 262 646 3341
HSU Fax 262 646 8731
Fox Lake Correctional Institution
Phone 920 928 3151
HSU Fax 920 928 6951
Green Bay Correctional Institution
Phone 920 432 4877
HSU Fax 920 432 1452
Jackson Correctional Institution
Phone 715 284 4550
HSU Fax 715 284 7373
Kettle Moraine Correctional Institution
Phone 920 526 3244
HSU Fax 920 526 3819
Lincoln Hills School
Phone 715 536 8386
HSU Fax 715 536 8385
Milwaukee Secure Detention Facility
Phone 414 212 3535
HSU Fax 414 225 5661
MANAGEMENT STAFF
Nurse Clinician 4
Physician
Dentist
Psychiatrist
Manager
DIRECT PHONES
Physician
Ext. 9218
Dentist
Psychiatrist
Manager
Ext. 9211
Physician
920 324 6482
Dentist
Psychiatrist
Optometrist
Manager
920 324 6268
920 324 6235
920 324 6534
920 324 6335
Physician
920 324 6322
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
920 324 6268
920 324 8317
Ext 354
Ext 601
Ext 347
Ext 240
920 928 6960
920 928 6927
920 928 6949
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Ext. 9214
920 324 6266
Ext. 432
Ext. 433
Ext. 438
715 284 7370
715 284 7375
715 284 7478
715 284 7080
920 526 9206
Ext. 233
Ext. 234
Ext. 236
715 453 7200
715 842 8600
414 212 4967
414 225 5668
414 225 5671
414 225 5666
FACILITY DIRECTORY
DEPARTMENT OF CORRECTIONS HEALTH SERVICES (HSU)
FACILITY
New Lisbon Correctional Institution
Phone 608 562 6400
HSU Fax 608 562 7382
Oakhill Correctional Institution
Phone 608 835 3101
HSU Fax 608 835 9198
Oshkosh Correctional Institution
Phone 920 231 4010
HSU Fax 920 326 2628
Prairie du Chien Correctional Institution
Phone 608 326 7828
HSU Fax 608 326 7736
Racine Correctional Institution
Phone 262 886 3214
HSU Fax 262 886 3858
Racine Youthful Offender Correctional
Facility
Phone 262 638 1999
HSU Fax 262 638 2940
Redgranite Correctional Institution
Phone 920 556 2600
HSU Fax 920 566 3166
Program Assistant 920 566 3165
Southern Oaks Girls School
Phone 262 878 6500
HSU Fax 262 878 6005
Stanley Correctional Institution
Phone 715 644 2960
HSU Fax 715 644 3764
Sturtevant Transitional Facility
Phone 262 884 2410
HSU Fax 262
Taycheedah Correctional Institution
Phone 920 929 3800
HSU Fax 920 929 2067
MANAGEMENT STAFF
DIRECT PHONES
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
608 562 7381
Psychiatrist
920 231 4010 Ext. 2259
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Ext. 411
Physician
Ext. 2237
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
Nurse Clinician 4
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
262 638 2954
Ext. 2927
920 566 3164
- 13 -
608 835 6070
Ext. 6071
Ext. 6080
Ext. 6075
920 236 2630
920 236 2267
920 236 2261
Ext. 131
Ext. 549
Ext. 561
262 638 2929
920 566 3221
920 566 3167
262 878 6562
262 878 6060
262 878 6558
3760
3763
3170
3154
262 886 6016
262 886 5020
920 929 3859
920 929 3856
920 929 3857
920 929 3856
FACILITY DIRECTORY
DEPARTMENT OF CORRECTIONS HEALTH SERVICES(HSU)
FACILITY
Waupun Correctional Institution
Phone 920 324 5571
HSU Fax 920 324 7254
Wisconsin Resource Center
Dept. of Health and Family Services
Phone 920 426 4310
HSU Fax
Wisconsin Secure Program Facility
Phone 608 375 5656
HSU Fax 608 375 2678
MANAGEMENT STAFF
Manager
Physician
Dentist
Psychiatrist
Director of Nursing
Physician
Dentist
Psychiatrist
Manager
Physician
Dentist
Psychiatrist
DIRECT PHONES
920 324 7258
920 324 7259
920 324 7259
920 236 4189
Ext. 4111
Ext. 2298
Ext. 4111
608 375 6432
608 375 6433
608 375 6433
608 375 6433
Questions related to individual correctional facility’s capabilities are addressed in this manual or may be
discussed by calling the Facility Health Services Unit or the Bureau of Health Services(see directory).
Questions regarding the correctional Centers should be directed to Susan Koon at 920-929-3884 or 608
240 5127or to one of the two Nursing Specialists listed on page 16.
- 14 -
CORRECTIONAL CENTER DIRECTORY
Note: Centers do not have daily nursing coverage with the exception of Burke and Ellsworth. Contact
the nurse at the center first and then contact the Nursing Specialist listed.
CENTER
Black River
Phone 715 333 5681
Fax 715 333 2708
Drug Abuse
Phone 920 236 2700
Fax 920 236 2701
Felmers O Chaney
Phone 414 874 1600
Fax 414 874 1695
Flambeau
Phone 715 585 6394
Fax 715 585 6563
Gordon
Phone 715 376 2680
Fax 715 376
John C. Burke
Phone 920 324 3460
Fax 920 324 3251
NURSE
NURSING SPECIALIST
920 236 2743
920 236 2743
414 576 4592
920 236 2743
920 236 2743
Manager
Physician
Dentist
Psychiatrist
920 324 3024
Kenosha
Phone 262 653 7099
Fax 262 653 7241
Marshall Sherrer
Phone 414 343 5001
Fax 414 343 5039
McNaughton
Phone 715 277 2484
Fax 715 277 2293
414 576 4592
Milwaukee Womens
Phone 414 267 6115
Fax 414 267 6130
Oregon
Phone 608 835 3233
Fax 608 835 3175
Robert E. Ellsworth
Phone 262 878 6000
Fax 262 878 6015
414 576 4592
44 576 4592
920 236 2743
414 576 4592
Manager
Physician
Dentist
Psychiatrist
262 878 6008
262 878 6007
262 878 5081
262 878 6007
920 236 2743
St. Croix
Phone 715 246 6971
Fax 715 246 3680
Sanger B. Powers
Phone 920 869 2650
Fax 920 869 2650
920 236 2743
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CORRECTIONAL CENTER DIRECTORY
Note: Centers do not have daily nursing coverage with the exception of Burke and Ellsworth. Contact
the nurse at the center first and then contact the Nursing Specialist listed.
CENTER
Thompson
Phone 608 423 3415
Fax 608 423 9852
Winnebago
Phone 920 424 0402
Fax 920 424 0430
NURSE
NURSING SPECIALIST
414 576 4592
920 236 2743
- 16 -
Health Services Program for Incarcerated Adults/Youths
Health care for incarcerated inmates/youths in Wisconsin Department of Corrections facilities is directed by the
Bureau of Health Services (BHS), Division of Adult Institutions (DAI), the Division of Juvenile Corrections
(DJC), and the facility Wardens/ Superintendents. The Bureau of Health Service’s mission is to provide
leadership for the delivery of cost-effective, high quality health care, health education, and preventive care in
accordance with professional, community, and constitutionally mandated correctional health care standards.
There are three health services delivery systems in the Department of Corrections. The first is the
standardized Health Services Unit, which delivers preventive, ambulatory, emergency, acute, and chronic
care and health education to offenders residing in adult or juvenile facilities. The second is the specialized
Health Services Unit designed to serve specific needs of the offender population: admissions,
hemodialysis, twenty-four hour nursing care, and offenders in minimum security correctional centers. The
third system provides specific health services to all offenders: pharmacy services, medical records, and
health contract monitoring.
The standardized Health Services Unit provides medical, nursing, dental, optometric, diagnostics
(laboratory and x-ray), pharmaceuticals, therapy (physical, occupational, and communication) care for
offenders. The offender health care status ranges from well to terminally ill. Health Services Units are
available in all maximum, medium, our one minimum facility, two female minimum security centers and
the three juvenile schools for youth.
Offenders receive a health screening and record review when transferred from one facility to another.
Preventative care is provided via communicable disease screenings and immunizations. Offenders have
access to health care via appointments either initiated by the offender (which generates a co-payment
charge) or by the health care provider. Staff provides emergency care until the concern is resolved or the
offender is transported via state vehicle or ambulance to an outside emergency room or to our contractual
specialty and inpatient care providers. Acute care is handled via appointments and may result in transfer to
the Infirmary or to an inpatient care provider for specialty or inpatient care including surgical procedures.
Chronic care is provided through appointments with on site health care providers and off site health care
providers if necessary. Health education is provided by staff to educate offenders in preventative
measures, about their conditions and the care needed for them including their participation.
Specialized health care is provided at the Dodge Correctional Institution and consists of admissions,
infirmary care, and hemo-dialysis. Health care is also delivered in the Correctional Centers utilizing
contractual nurses and community providers.
Each admission is provided with an examination and evaluation of their health status. Adult males report
to Dodge Correctional Institution and adult females report to the Taycheedah Correctional Institution and
are seen by the staff in the primary care unit. Each juvenile facility does their own admission procedures
on site. A history and physical is done including laboratory tests, tests for communicable diseases, and xrays if needed. A medical record including dental and optometric as well as medical is started for each
offender and follows them throughout their incarceration providing information to all health care providers
regarding the offender’s health status. Pharmaceuticals are provided if needed for the offender’s medical
condition. Vision is tested and glasses are provided if needed via state contract. A complete dental
examination with x-rays is done and a dental plan of care developed. Medical and dental classifications are
done for the use of the Program Review Committee to determine housing and program assignments for the
offender considering their health status.
- 17 -
The hemo-dialysis unit provides hemo-dialysis to a maximum of eighteen adult male offenders.
Treatment is provided on site by nurses trained in hemo-dialysis. A contractual nephrologist makes regular
site visits and oversees the treatment of offenders with end stage renal disease.
Offenders needing twenty-four hour nursing care reside in the Infirmary at Dodge with twenty-four hour
staffing. The Infirmary provides a level of care between that of housing units with no medical staff and
that of a hospital such as the University of Wisconsin Hospital and Clinics or the Waupun Memorial
Hospital. The Infirmary has room for sixty-four offenders, eight beds for females, and five negative
pressure cells.
Offenders residing in minimum-security correctional centers receive health care via on site staff,
contractual or Limited Term nurses and physicians, or utilizing community health care providers. Nurses
conduct sick call and triage complaints making arrangements for further care as needed. A Nursing
Coordinator and two Nursing Specialists provide direction and oversight to this program. There are sixteen
correctional centers located throughout the State.
Three units located at Dodge Correctional Institution in Waupun provide specialized services for the entire
Department.
Pharmacy services for the system are centralized in Waupun. The Unit receives prescriptions from all
facilities, packages drugs in blister packs for security purposes, and sends the pharmaceuticals via UPS to
the HSU drug rooms for further processing and distribution by the health care staff. The Department
purchases pharmaceuticals via a multi-group agreement negotiated by DOA resulting in less than retail cost
for the pharmaceuticals used. The system has a drug formulary and an active Pharmacy and Therapeutics
Committee.
Medical records of those offenders who have left the system are maintained at the Central Medical
Records Center in Waupun. Health Information Technicians manage the records, establish new records for
admissions, and respond to requests for information from community care providers, attorneys,
governmental agencies, etc.
All out of state contractual units (CCA—Minnesota) and inmates housed in county jails per contract are
monitored by the Contract Monitoring Unit. A Contract Monitor who is a nurse makes regular
announced and unannounced visits to monitor and audit the care given.
The Department has Clinical Directors in the fields of medicine, psychiatry, and dentistry to maximize
the practice of the employees, develop cost effective programs for care delivery, and monitor the cost of
the programs. Prior authorization of all off site non-emergency services is done by the Clinical Directors
for their areas.
To further address specialty needs of offenders in a cost-effective manner, on site clinics have been
established for orthopedics, and oral surgery at designated institutions. Offenders are transported for
appointments from nearby facilities reducing our trips to the University of Wisconsin Hospital and Clinics.
Telemedicine is being operationalized at nine adult facilities(Columbia, Dodge, Green Bay, Jackson,
Oshkosh, Racine, Redgranite, Waupun, and Wisconsin Secure) to eliminate the need for transportation and
escort to Madison for specialty consultation.
The Department has memos of understanding or contracts with agencies in the State to provide further
cost efficiencies in the delivery of health care to offenders. Marquette University School of Dentistry
- 18 -
provides dental care to offenders in the correctional centers in Milwaukee County. Dynacare Labs
provides all laboratory services for the facilities. X-ray processing and interpretation are provided by
mobile x-ray services throughout the state and by the Radiological Associates in Beaver Dam. The State
Laboratory of Hygiene and Division of Public Health provides communicable disease screening as part of
their State public health initiative. Immunization materials are provided through the Division of Health
and Federal Immunization Program. Contracts with local hospitals and clinics provide specialty care, and
inpatient services.
- 19 -
Medical/Surgical Classification
Prior authorization is required for all non-emergency procedures. Specialists and Off Site Physicians will be asked
to classify surgical and medical procedures as follows:

CLASS I: Emergency Care – Medically Mandatory
An emergency is a potentially life-threatening condition requiring immediate care. A delay in treatment may
result in death or permanent serious impairment of the patient’s health.
Examples of emergency care conditions include those which pose a threat to vital organs and/or shock as in
major burns, suspected myocardial infarction, hematemesis, acute nephrolithiasis or closed head injury with
loss of consciousness.
No prior authorization to proceed with care is required.

CLASS II: Urgent Care – Presently Medically Necessary
An urgent care problem, while not an emergency, is one, which if not treated within a reasonably accepted time
as determined by the physician has the potential to threaten life or limb. The patient requires prompt attention
for diagnosis or treatment of the condition. Delay of treatment would present a medically unacceptable risk for
serious bodily harm, disability, or further deterioration in the patient’s condition.
Urgent health care problems may be marked by rapid onset of severe pain, persistent severe pain, or unusual
discomfort associated with illness or impairment. Examples of urgent care problems include urinary tract
infections, fractures, and cases involving an acute episode of severe intractable pain during or after a regimen
of narcotic therapy.
No prior authorization to proceed with care is required.

CLASS III: Non-urgent care – Medically Acceptable
A non-urgent condition is one which at present does not represent a significant threat to the patient’s general
medical health and which is not likely to pose such a threat in the foreseeable future. Medical and surgical
procedures can be performed at the convenience of the physicians, persons and institutions involved. Nonurgent cases are of two types:
Class III-A: Those involving persistent pain and experiencing serious discomfort, or rapidly progressive disease
or impairment, or where severity of pain has been progressive. The condition must be subject to surgical or
medical correction or arrest. While no ill effects will potentially result from a delay of several weeks or
months, adequate care dictates the performance of medical or surgical intervention as soon as scheduling will
reasonably permit. Examples: symptomatic ulcerated varicosities, non-incarcerated symptomatic hernias, large
hemorrhoids, and painful bunions.
Class III-B: Those not involving persistent pain, rapidly progressive disease or impairment and not solely for
the convenience of the patient. No negative effects will result from surgical delay of months or years. This is
the sort of procedure which a non- institutionalized or uninsured person might choose to delay until he / she
becomes medically insured. Examples: asymptomatic hernias for sedentary patients, benign non-inflammatory
cysts, orthopedic problems where there is no persistent pain or inflammation, minor nasal reconstruction, noncancerous skin lesions, and cases manageable with non-narcotics.
In both instances, prior authorization is required.

CLASS IV: Elective Non-Covered Care Services - Convenience of Inmate / Youth
- 20 -
A non-covered service is one that, although desirable for psychological or personal reasons, is not authorized
under the Bureau of Health Services health care plan. These services are
not reasonably or medically necessary or required in accordance with accepted medical
standards or surgical practice. Examples: fertility and contraceptive surgery, elective
circumcisions, weight reduction surgery, experimental treatment or surgery, professional
services by a chiropractor, plastic or cosmetic surgery unless necessary to achieve normal
bodily function after accidental bodily injury occurring while in state custody.
Prior authorization is required but is seldom approved.
- 21 -
HEALTH CARE SERVICES PROVIDED WITHIN CORRECTIONS
Central Medical Records
Dialysis

Maintains inactive medical records for all inmates
released from the Department of Corrections.

Eighteen beds available for adult males at Dodge Correctional
Institution
Female inmates and youth receive treatment at local hemodialysis
centers.
Adult male inmates receiving hemodialysis at community
hemodialysis centers should be referred to DCI hemodialysis to be
placed on a waiting list and transferred to DCI when treatment is
available.
Nephrologist to Nephrologist referral is necessary.



Dietary Services
Emergency Care
Intake


Dieticians available centrally.
Special diet consultation may be coordinated through the Health
Services Manager.

Local hospitals until patient is stabilized. Disposition is then
decided upon by the Health Services Manager and the facility
physician (or physician on call) according to the medical needs of
the inmate in consultation with the ER physician. Complete orders
from the ER physician are needed because physician availability at
facilities may be limited.

All adult males and females are assessed and evaluated at Dodge
Correctional Institution or Taycheedah Correctional Institution
respectively.
All youth inmates are assessed and evaluated at their respective
facilities (Ethan Allen School, Lincoln Hills School or Southern
Oaks Girls School).

Laboratory
Long Term Care
Pharmacy





Dynacare Laboratories-Milwaukee
State Lab of Hygiene – Madison—communicable diseases
Facility On-Site: phlebotomy, urine analysis by Dipstix, capillary
blood glucose, stool for occult blood, and pregnancy testing at
female facilities
Some Correctional Centers may use off-site providers
Local providers may be used for STAT needs



Infirmary at Dodge Correctional Institution
Bed Capacity for adult males and females
Negative pressure isolation cells available


Services for all correctional facilities provided
Stat medications and initial scheduled narcotics may be obtained
through a local pharmacy.
Limited stock of frequently used medications are on-site.

- 22 -
Psychiatric Services
Psychological Services
Primary Care Services


Available at Correctional Institutions and Schools for psychotropic
medication management.
Psychiatric coverage is limited at Correctional Centers

Available at all facilities.

Primary Care medical services provided by a physician or nurse
practitioner.
- 23 -
Medical Services Available at Individual Facilities
Facility
Columbia C. I.
Health Education
Group programs as time
permits
Nutrition
Individual counseling as to
appropriate choices from menu
provided.
Individual counseling as to
appropriate choices from menu
provided.
Individual counseling as to
appropriate choices from menu
provided
Physical Therapy
Sitz bath, whirlpool, ultra
sound
Dodge C. I.
One on one
Fox Lake C. I.
One on one
Green Bay C. I.
One on one
Special diets are available with
medical orders and are served
in the main dining room.
Sitz baths. PT on site per
local provider when
possible
Jackson C. I.
One on one
Individual counseling as to
appropriate choices from menu
provided
John C. Burke C.C.
Handouts and classes
as time permits
Kettle Moraine C. I.
One on one. Life skills
at School module at
Stop Nexus program
Individual counseling as to
appropriate choices from
menu provided.
Individual counseling as to
appropriate choices from
menu provided.
Ultrasound, whirlpool,
sitz bath, supervised
exercise, splint /
appliance assessment.
Contracted for on onsite
PT
Milwaukee Secure
Detention Facility
One on one
Oakhill C. I.
One on one
Self select from daily
Menu. Limited special diets
provided.
Individual counseling as to
appropriate choices from menu
provided.
- 24 -
Contracted and includes
occupational therapy and
communication therapy.
Sitz bath, supervised
exercises, weights,
hydrocollator, and Kpacks.
X-Ray
On site weekly routine chest,
extremities, etc. Emergencies
at Divine Savior Hospital
On site
On site weekly routine chest,
extremities, etc.
Emergencies and specials
done at Waupun
Memorial Hospital.
On site routine chest,
extremities, etc.
Emergencies and specials at
Bellin Hosp.
On site routine chest,
extremities, etc., on Tues. &
Wed. Emergencies done at
Black River Mem. Hosp
Onsite, mobile unit
PT on site
X-ray Mobile comes to
institution one time per
week.
N/A
On Site weekly provided by
Mobile Diagnostic Services.
Sitz bath
Contracted PRN
Tri-County Mobile per
capabilities of portable unit,
weekly & prn
Emergencies & specials at
UWHC
Facility
Health Education
Nutrition
Physical Therapy
Oshkosh C. I.
One on one by health
care providers as needed
Individual counseling as to
appropriate choices from menu
provided.
On site by a private vendor.
X-ray equipment on site.
Prairie du Chien C. I.
One on one routine
health teaching, monthly
presentation of
prevention topics,
annual wellness clinic.
Individual counseling provided
by HSU RN’s & contracted
dietician. Inmates requiring
special diets are given special
trays.
Sitz bath, supervised
exercises, whirlpool,
diathermy, and
ultrasound. Evaluations
and treatments are
provided by contract
providers.
Prescribed plans
monitored by HSU staff.
Assessments, evaluations
and on-going therapies
are provided at Prairie du
Chien Mem. Hosp.
Redgranite
Correctional
Institution
One on one by HSU
staff concerning
medication, diet,
personal and health care.
Maintenance of chronic
conditions.
One on One concerning
substance abuse, first
aid, planned
parenthood, health
fitness, preventive
health, prenatal care, &
parenting.
Individual counseling
and group education
Individual counseling provided
by HSU RN's & contracted
Dietician.
Physical therapist
provides consults 4
hours/week, set-up
programs for patients
including whirlpool
therapy.
Off site-PT, OT services
provided by MJ Care.
Mobile Diagnostics for
routine films on site. X-ray
equipment on site.
Robert Ellsworth
C.C.
Stanley C.I.
Individual counseling as to
appropriate choices from
menu provided.
Individual counseling and
written materials.
- 25 -
PT,OT Services provided
on-site by Our Lady of
Victory Hospital Therapy
Department, as MJ Care
is not able to meet
contract needs.
X-Ray
Tri-County Radiology
Services for routine films on
site; other services scheduled
at UWHC or Lacrosse
Gunderson.
Imaging.Mammography to
UW Hosp., Madison or St.
Mary’s Hosp., Racine.
Onsite routine X-Ray &
screening. Diagnostic
referred to UW or St.
Mary’s.
Completed on-site. DMS
Imaging uses X-ray
equipment that is at the
institution. ER X-Ray
services completed at Our
Lady of Victory Hospital.
Facility
Sturtevant
Transitional Facility
Health Education
One on one.
Nutrition
Individual counseling
regarding appropriate choices
from menu provided.
Physical Therapy
Evaluations and
treatments are provided
by contract provider-MJ
Care.
X-Ray
Portable x-ray on site per
contract vendor. Emergency
x-rays at St. Mary’s or St.
Lukes Hospital in Racine.
Taycheedah C. I.
One on one concerning
substance abuse, first
aid, planned
parenthood, health
fitness, preventive
health, prenatal care, &
parenting.
One on one and group
programs
Individual counseling as to
appropriate choices from
menu provided.
PT, OT services
provided by Agnesian
Homecare.
On site routine X-Ray &
screening mammography.
Diagnostic referred to St.
Agnes Hospital
General diet is low fat, low
cholesterol, low salt. A
dietician is available to assist
with planning other diets as are
medically indicated.
General diet is low fat, low
cholesterol, low salt. A
dietician is available to assist
with planning other diets as are
medically indicated.
On site contracted
services
On site routine x-rays
Referred to UW Hospital
On site routine x-rays
Nutrition per medical orders
and according to DOC dietary
manual. Food services will
provide special diets.
On site contracted
services.
Routine on site with mobile
equipment – specials at
Memorial Hospital at
Oconomowoc or UWHC
Waupun C. I.
Wisconsin Secure
Program Facility
One on one.
Ethan Allen School
One on one and group
concerning first aid,
HIV, hygiene, asthma,
TB, acne, body systems,
and human sexuality.
- 26 -
Facility
Lincoln Hills School
Health Education
One on one. Basic health
education on HIV,
testicular self exam, and
personal hygiene for
groups of students.
Nutrition
Limited special diets
provided by food services
Racine Youth Inmate
Correctional Facility
One on one. Basic and
topic specific health
education provided in
collaboration with the
RYOCF Warren Young
School / Education
Department
Individual counseling as
to appropriate choices
from menu provided.
Special diets per food
services with medical
order and according to
DOC dietary manual.
Southern Oaks Girls
School
One on one and group
education for HIV, SBE,
personal hygiene, STDs,
birth control, asthma,
TB, diabetes, pregnancy,
and other basic health
education.
Per medical order and
DOC Dietary Manual.
Very limited special
diets provided by
REECC food services.
- 27 -
Physical Therapy
Sitz baths, supervised
exercises. Referred to
Sacred Heart Hospital,
Tomahawk and
supervised by nurse at the
school under the direction
of a therapist.
Sitz bath, supervised
exercises, whirlpool,
ultrasound, bicycle,
hydrocollator, & K-pack.
Weights for quads and
shoulder exercises to 20
lbs. Contract services as
needed
N/A
X-Ray
On site with mobile
equipment. Preps for
contrast x-rays.
Emergency x-rays at
Sacred Heart.
Portable x-ray on site per
contract vendor.
Emergency x-rays at St.
Mary’s or St. Lukes
Hospital in Racine.
Routine on site with
mobile equipment.
Specials to All Saints.
NURSING AVAILABILITY HOURS
Monday - Friday
Sat, Sun, & Holidays
On Call Staff
0600-2000
None
Yes
0600 – 2200
0600 – 1400
Yes
0630 – 2215
0630 – 2215
24 hours/day
24 hours/day
Infirmary Nursing
Staff
N/A
0600 – 2200
0800 – 1600
Yes
M -Th: 24 hours/day
Friday 0600-2200
0800 – 2000
Yes
0630 – 2230
0800 – 1600
Yes
On Call RN
Yes
0600 – 2200
0600 – 1400
Yes
24 hours/day
24 hours/day
N/A
0630-2200
0800-1600
Yes
0730 – 1630
On call RN
Yes
0630 – 2230
0630 – 1430
Yes
0600 – 2300
0600 – 1500
Yes
0700 – 2300
0700 – 1500
Yes
0700 – 2200
0800- 1600
Yes
24 hours Sunday-Friday
1000-1800
Yes
600-2200
600-1400
Yes
24 hours/day
24 hours/day
No
0700-2000
On Call
Yes
24 hours on-site
24 hours on-site
N/A
0600 – 2200
0600 – 1400
Yes
24 hours on-site
24 hours on-site
N/A
0630 – 2200
On call
Yes
Lincoln Hills School
715-536-8386
0700 – 2300
0700 – 1700
Yes
Southern Oaks Girls School
262-878-6574
0600 – 2200
1200 – 2200
Yes
Facility
Chippewa Valley CTF
715-720-2850
Columbia C. I.
608-742-9100
Dodge C. I. Primary
920-324-6266.
Dodge C. I. Infirmary
920-324-6236
Fox Lake C. I.
920-928-6927
Green Bay C.I.
920-432-4877
Jackson C. I.
715-284-4550
John C. Burke C.C.
920-324-9987
Kettle Moraine C. I.
920-526-3244
Milw. Secure Detention Facility
414-225-5663
New Lisbon C.I.
608-562-7381
Oakhill C. I.
608-835-3101
Oshkosh C. I.
920-231-4010
Prairie du Chien C. I.
608-326-7828
Racine C. I.
262-886-3214
Racine Youth Off. Corr. Facility
262-638-1999
Redgranite C.I.
920-566-3164 & 3167
Robert Ellsworth Corr. Center
262 878 6000
Stanley C.I.
715-644-2960
Sturtevant Trans. Fac
262-884-2410
Taycheedah C. I.
920-929-3900
Waupun C. I.
920-324-5571
Wisconsin Secure Program
Facility
608-375-6433
Ethan Allen School
262-646-3341 x315
0630-2000
- 28 -
Handicap and Special Needs Availability
Facility
Chippewa Valley CTF
Columbia C. I.
Dodge C. I.
Fox Lake C. I.
Green Bay C. I.
Jackson C. I.
Kettle Moraine C. I.
Milwaukee Secure
Detention Facility
New Lisbon C.I.
Oakhill C. I.
Oshkosh C. I.
Prairie du Chien C. I.
Racine C. I.
Redgranite C.I.
Stanley C.I
Sturtevant Transitional
Facility
Taycheedah C. I.
Waupun C. I.
Handicap Accessibility & Special Needs Availability
Wheelchair accessible. Wheelchair ramps available at building entrances. Elevator
available for each floor of the facility.
Wheelchair accessible. All buildings have ramps. One housing unit has wheelchair
elevator and 12 cells that are barrier free. Other than wheelchair unable to
accommodate inmates that cannot navigate stairs.
Accessible
Accessible. All service buildings and one housing unit have ramps. The Health
Services Unit has an elevator
The Health Services Unit, service buildings, and one small housing and segregation
unit have ramps. General population housing units are not handicap accessible.
Stairs must be climbed for meals, showers and recreation.
All service buildings and housing unit are handicap accessible.
One living unit accessible (shower equipped with side bars). Inmates must travel a
distance outdoors, up and down hills from living units and Health Services Unit
Accessible. All floor may be accessed by elevator. Sixteen lower cells that are
barrier free. Sixteen upper cells with limited accessibility. Must be ambulatory
with assistive devices.
All service buildings and housing units are handicap accessible.
Not accessible to handicapped. Must be ambulatory with assistive devices.
Ground floor units are handicap accessible.
All buildings are equipped with ramps and all floors may be accessed by elevator
with permission.
Institution has ramps and elevators.
Accessible
Accessible
Accessible
Accessible
The Health Services Unit and segregation unit are handicapped accessible. General
housing units within the institution are not handicap accessible. Stairs must be
climbed for meals, showers, and recreation. Inmates must walk outdoors to access
the HSU building.
Wisconsin Secure
Program Facility
Accessible. Must be independent with ADLs.
Ethan Allen School
One cottage and the Health Services Unit are handicap accessible. All cottages and
buildings have ramps. All buildings that are greater than one story have elevators.
Lincoln Hills School
Racine Youth Inmate
Correctional Facility
Southern Oaks Girls
School
Limited handicap accessibility
All housing units and common areas meet ADA standards for handicap accessibility.
Accessible
- 29 -
Jim Doyle
Governor
Matthew J. Frank
Secretary
State of Wisconsin
Department of Corrections
Mailing Address
Bureau of Health Services
3099 E. Washington Ave.
Post Office Box 7925
Madison, WI 53707-7925
Telephone (608) 240-5120
Fax (608) 240-3311
April 22, 2004
TO:
Community Health Care Providers of Hospitalized
Department of Corrections’ Patients
FROM:
James Greer, Director
Bureau of Health Services
SUBJECT: Case Management by the Bureau of Health Services
The Bureau has assigned two Nursing Specialists to provide case management to hospitalized patients from the
Department of Corrections facilities.
They will be monitoring the care and treatment of hospitalized inmates and planning their discharge for continuity
of care purposes with the local care providers and the health care staff of the correctional facilities where the
inmates will return.
The Discharge Planners and their phone numbers are:
Linda Kleinsteiber, RN, MS
608 240 5125
Lynn Yarbrough, RN, NS
608 240 5134
They will be contacting the local health care provider for updates on the condition of the patient while
hospitalized. They will need to know potential discharge dates in order to facilitate transfer back to the sending
facility or transfer to another facility including the Infirmary with 24 hours nursing coverage to facilitate
continuity of care and continued recovery of the patient. They will need to arrange a telephone conference
between the receiving Primary Care Physician and the Physician caring for the patient during his/her
hospitalization.
I ask that you provide them the information they request and assist them to assure a positive outcome for the
hospitalized patient.
Should you have questions or concerns that Ms. Kleinsteiber and Ms. Yarbrough are unable to address, please
contact me directly at 608 240 5122,
Thank you in advance for your assistance.
DEPARTMENT OF CORRECTIONS
Division of Adult Institutions
DOC-3001 (Rev. 9/03)
WISCONSIN
OFF SITE SERVICE REQUEST AND REPORT
REQUEST
PATIENT NAME Last
First
MI
REFERRED TO
DOC NUMBER
UW MED. RECORD #
DATE OF BIRTH
CLINIC / FACILITY
TELEMEDICINE
Yes
REFERRAL INSTRUCTIONS
Diagnosis Only - DO NOT START TREATMENT
Complete The Treatment
Recommended Plan of Care
Returning For Ongoing Care
Start Treatment, But Return To HSU MD For Completion
Other
RELEVANT SYMPTOMS / PROBLEMS / DIAGNOSIS
ALLERGIES
MEDICATIONS:
See Attached
QUESTIONS / OUTCOMES TO BE ADDRESSED BY THIS EVALUATION
ADDITIONAL DATA ENCLOSED
Progress Note Extracts
X-ray Reports, Films
Other
Laboratory Test Results
OUTPATIENT CONTACT DATE
TIME
REFERRED BY
HSU
AM
PM
OR
TELEPHONE NUMBER
ADMISSION DATE
FAX NUMBER
DATE SIGNED
REPORT
PRIMARY DIAGNOSIS /OTHER(S) DIAGNOSIS
PERTINENT HISTORY AND OBJECTIVE FINDINGS / TREATMENTS / PROCEDURES AND DIAGNOSTIC WORK PERFORMED
PLAN / RECOMMENDATION’S (Follow-up appointment via telemedicine?
Yes
No )
INDICATE CLASSIFICATION IF YOU ARE RECOMMENDING SURGERY OR A PROCEDURE (See Reverse Side for Description)
Class I
Class II
PHYSICIAN NAME (Please Print)
HOSPITAL/ CLINIC NAME
Class III-A
Class III-B
Class IV
Non-Surgical
PHYSICIAN SIGNATURE
TELEPHONE NUMBER
DISTRIBUTION: ORIGINAL – DOC Medical Record (Consultation Section); Copy – Off-Site Provider’s Medical Record
- 31 -
DATE SIGNED
No
CLASSIFICATION OF MEDICAL AND SURGICAL CONDITIONS
Class I:
EMERGENCY CARE - MEDICALLY MANDATORY
An emergency is a potentially life-threatening condition requiring immediate care. A delay in
treatment may result in death or permanent serious impairment of the patient's health.
Class II:
URGENT CARE - PRESENTLY MEDICALLY NECESSARY
An urgent care problem, while not an emergency, is one which delay of treatment would present a
medically unacceptable risk for serious bodily harm, disability, or further deterioration in the patient's
condition.
No prior authorization to proceed with care is required for Class I or II.
Class III:
NON-URGENT - MEDICALLY ACCEPTABLE
A non-urgent condition is one which at present does not represent a significant threat to the patient's
general medical health and which is not likely to pose such a threat in the foreseeable future.
Surgical procedures can be performed at the convenience of the physicians, persons and institutions
involved. Non-urgent cases are of two types:
Class III-A: Those involving persistent pain and experiencing serious discomfort or rapidly
progressive disease or impairment, or where severity of pain has been progressive. The condition
must be subject to surgical or medical correction or arrest. While no ill effects will result from a delay
of several weeks or months, adequate care dictates the performance of medical or surgical
procedures as soon as scheduling will reasonably permit. Examples include symptomatic ulcerated
varicosities, non-incarcerated symptomatic hernias, large hemorrhoids, and painful bunions.
Class III-B: Those not involving persistent pain, rapidly progressive disease or impairment
and not solely for the convenience of the patient. No medical effects will result from surgical delay of
months or years. This is the sort of procedure which a non-institutionalized or uninsured person
might choose to delay until he / she becomes medically insured. Examples include asymptomatic
hernias for sedentary patients, benign non-inflammatory cysts, orthopedic problems where there is
no persistent pain or inflammation, minor nasal reconstruction, non-cancerous skin lesions, and
cases manageable with non-narcotics.
In both instances, prior authorization is required.
Class IV: ELECTIVE NON-COVERED CARE SERVICES - CONVENIENCE OF OFFENDER
These services are not reasonably or medically necessary or required in accordance with accepted
medical standards for medical or surgical practice. Examples include, fertility and contraceptive
surgery, elective circumcisions, weight reduction surgery, experimental treatment or surgery,
professional services by a chiropractor, plastic or cosmetic surgery unless necessary to achieve
normal bodily function after accidental bodily injury occurring while in state custody. These are not
authorized under the Bureau's health care plan.
FORMULARY
The drug formulary for the Department of Corrections is included to assist off site providers
in prescribing medications for inmates/youth. Medications prescribed, which are not found
in this formulary will require prior authorization by the Medical Director of the Bureau of
Health Services.
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INMATE HEALTH PLAN
The Inmate Health Plan describes the services and procedures available to inmates/youth in the
Department of Corrections.
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